Substance-use disorders: A
whirlwind tour
Anthony Worsham, MD
Best Practices
Division of Hospital Medicine
Department of Internal Medicine
University of New Mexico Health Sciences Center
Wednesday, June 19, 2013
The dose makes the poison
What is it that is not a poison? All
things are poison and nothing is
without poison. Solely, the dose
determines that a thing is not a
poison.
--Paracelsus (1493–1541), the
Renaissance Father of Toxicology,
in his Third Defense
Erickson TB, The approach to the patient with an unknown overdose,
Emerg Med Clin N Am 25 (2007) 249–281
http://en.wikipedia.org/wiki/Paracelsus
The publication of The Core Competencies…
represents the first attempt to define the
specialty of Hospital Medicine.
Purpose
The Core Competencies provide a framework
for professional and curricular development
based on a shared understanding of the
essential knowledge, skills and attitudes
expected of physicians working as hospitalists.
Core Competencies
Clinical Conditions
•Acute Coronary Syndrome
•Delirium and Dementia
•Acute Renal Failure
•Diabetes Mellitus
•Alcohol and Drug Withdrawal
•Gastrointestinal Bleed
•Asthma
•Hospital-Acquired Pneumonia
•Cardiac Arrhythmia
•Pain Management
•Cellulitis
•Perioperative Medicine
•Chronic Obstructive Pulmonary
Disease
•Sepsis Syndrome
•Community Acquired Pneumonia
•Urinary Tract Infection
•Congestive Heart Failure
•Venous Thromboembolism
•Stroke
Alcohol and Drug Withdrawal
Core Competency: Knowledge
Hospitalists should be able to:
•
Describe the effects of drug and alcohol withdrawal on medical illness and the effects of
medical illness on substance withdrawal.
•
Recognize the complications from substance use and dependency.
•
Distinguish alcohol or drug withdrawal from other causes of delirium.
•
Describe the indicated tests required to evaluate alcohol or drug withdrawal.
•
Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic
criteria for withdrawal.
•
Explain indications, contraindications and mechanisms of action of pharmacologic agents
used to treat acute alcohol and drug withdrawal.
•
Identify local trends in illicit drug use.
•
Determine the best setting within the hospital to initiate, monitor, evaluate and treat
patients with drug or alcohol withdrawal.
•
Explain patient characteristics that on admission portend poor prognosis.
•
Explain goals for hospital discharge, including specific measures of clinical stability for safe
care transition. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development.
Journal of Hospital Medicine. Volume 1, Issue S1, pages 6–7, 2006.
Alcohol and Drug Withdrawal
Core Competency: Skills
Hospitalists should be able to:
• Elicit a thorough and relevant history, with emphasis on substance use.
• Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC
drugs.
• Differentiate delirium tremens from other alcohol withdrawal syndromes.
• Assess for common co-morbidities in patients with a history of alcohol and drug use.
• Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal
and determine life-threatening co-morbidities.
• Apply DSM-IV Diagnostic Criteria for Alcohol Withdrawal.
• Formulate a treatment plan, tailored to the individual patient, which may include appropriate
pharmacologic agents and dosing, route of administration, and nutritional supplementation.
• Integrate existing literature and federal regulations into the management of patients with opioid
withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency,
communicate with outpatient treatment centers and integrate dosing regimens into care
management.
• Manage withdrawal syndromes in patients with concomitant medical or surgical issues.
• Determine need for the use of restraints to ensure patient safety.
• Reassure, reorient, and frequently monitor the patient in a calm environment.
• Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of
care required, and manage or co-manage the patient with the primary requesting service.
The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. Journal of Hospital Medicine.
Volume 1, Issue S1, pages 6–7, 2006.
Alcohol and drug withdrawal
Core competency: Attitudes
Hospitalists should be able to:
• Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and
the medical risks of drug and alcohol use.
• Communicate with patients and families to explain goals of care plan, discharge instructions and
management after release from hospital.
• Appreciate the indications for specialty consultations.
• Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.
• Manage the hospitalized patient with substance use in a non-judgmental manner.
• Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social
services, in the treatment of patients with substance use or dependency.
• Establish and maintain an open dialogue with patients and families regarding care goals and
limitations.
• Appreciate and document the value of appropriate treatment in reducing mortality, duration of
delirium, time required to control agitation, adequate control of delirium, treatment of
complications, and cost.
• Facilitate discharge planning early in the hospitalization, including communicating with the primary
care provider and presenting the patient with contact information for follow-up care, support and
rehabilitation.
• Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of
withdrawal symptoms. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development.
Journal of Hospital Medicine. Volume 1, Issue S1, pages 6–7, 2006.
Alcohol and drug withdrawal
Core competency: System Organization
and Improvement
To improve efficiency and quality within their organizations, Hospitalists
should:
• Lead, coordinate or participate in the development and promotion of
guidelines and/or pathways that facilitate efficient and timely evaluation
and treatment of patients with alcohol and drug withdrawal.
• Promote the development and use of evidence based guidelines and
protocols for the treatment of withdrawal syndromes.
• Advocate for hospital resources to improve the care of patients with
substance withdrawal, and the environment in which the care is delivered.
• Lead, coordinate or participate in multidisciplinary teams, which may
include psychiatry, to improve patient safety and management strategies
for patients with substance abuse.
The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. Journal of
Hospital Medicine. Volume 1, Issue S1, pages 6–7, 2006.
Camí J, Farré M, Drug Addiction, N Engl J Med, 2003;349:975-86.
Renner JA, Ward EN, Drug Addition, Massachusetts General Hospital Comprehensive Clinical Psychiatry
Identify local trends in illicit drug
use
New Mexico Department of Health . New Mexico Substance Abuse Epidemiology Profile: July
2011.http://nmhealth.org/erd/SubstanceAbuse/2011%20New%20Mexico%20Substance%20Ab
use%20Epidemiology%20Profile.pdf
49% Prescription opioids(i.e.,methadone,oxycodone,morphine)
36% heroin
31% cocaine
29% tranquilizers/musclerelaxants
16% antidepressants
median age of unintentional drug overdose: 43.7years
Elicit a thorough and relevant history,
with emphasis on substance use
Obtain all prescription bottles and other containers when possible. Perform a pill count. Be sure
that the bottles contain the medications listed. Identify any unknown tablets.
Contact the prescribing physician(s) or the pharmacy as listed on the bottles to determine
previous overdoses or other medications that the patient may have available.
Identify underlying medical and psychiatric disorders and medication allergies. Review past
medical records.
Talk to the patient’s family and friends in the emergency department. If necessary, call the
patient’s home to ask questions of others. The persons providing the important elements of
the history should be identified in the chart.
Search the patient’s belongings for drugs or drug paraphernalia. A single pill hidden in a pocket,
for example, may provide the most important clue to the diagnosis.
Have family members (or the police) search the patient’s home, including the medicine cabinet,
clothes drawers, closets, and garage: such searches may also provide clues that make the
diagnosis. This has the added benefit of involving the family in the patient’s care.
Always look for track marks on the patient. Consider body packing or body stuffing.
Kulig K, Ling LJ, General Approach to the Poisoned Patient. Rosen's Emergency Medicine, 7th
ed., 2009.
Approach to the poisoned patient
Erickson TB, The approach to the patient with an unknown overdose,
Emerg Med Clin N Am 25 (2007) 249–281
Ford MD, Acute Poisoning, Goldman's Cecil Medicine, 24th ed., 2011.
Recognize the symptoms and signs
of alcohol and drug withdrawal
Toxidrome: a constellation of signs and
symptoms characteristic of a class of drugs
Shannon MW, A General Approach to Poisoning, Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed., 2007.
Cholinergic syndrome
Mnemonics
DUMBBELS
• Defecation
• Urination
• Miosis
• Bronchorrhea
• Bronchoconstriction
• Emesis
• Lacrimation
• Salivation
SLUDGE
• Salivation
• Lacrimation
• Urination
• Defecation
• Gastrointestinal
dysfunction
• Emesis
Describe the indicated tests required
to evaluate alcohol or drug withdrawal
Bast RP et al, Limited Utility of Routine Drug Screening in Trauma Patients, Southern Medical
Journal, 2000, 397-399.
Limited utility of tox screens?
Diagnostic and management decisions are made before toxicologic test
results are returned.
Benign diagnostic intervention may preclude the need for these tests (e.g.,
response to naloxone in opiate intoxication
Few specific interventions or antidotal therapies depend on toxicologic test
outcomes.
The incidence of overall morbidity is low (less than 1%) in the setting of
optimal patient management, including decontamination and supportive
therapy.
Toxicity is often apparent on presentation.
There is a lack of rapid commercial assays for somedrugs commonly involved
in emergency room evaluations (e.g. oxycodone, ketamine, GHB).
Shannon MW, A General Approach to Poisoning, Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed., 2007.
ED Triage Protocol Tox-SI-OD
ED Triage Protocol Tox-SI-OD
ED AMS-Withdrawal
ED AMS-Withdrawal
Describe the indicated tests required to
evaluate alcohol or drug withdrawal
Osterloh JD, Haller CA, Laboratory Diagnoses and Drug Screening, Haddad and Winchester's Clinical
Management of Poisoning and Drug Overdose, 4th ed., 2007.
Moeller KE, Urine Drug Screening:
Practical Guide for Clinicians, Mayo
Clin Proc. 2008;83(1)66-76
Quantification of Toxins
Shannon MW, A General Approach to Poisoning, Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed., 2007.
Osmolar Gap
Levine M et al, Toxicology in the ICU: Part 1: General Overview and Approach to Treatment Chest
2011; 140( 3 ): 795 – 806
Poisoning pearls
• Protracted coughing with hydrocarbon
ingestions
• Inability to swallow or drooling with caustic
ingestions
• Hematemesis with iron ingestions
• Intractable seizures with isoniazid overdose
• Loss of consciousness with carbon monoxide
Guidelines for In-Hospital Disposition
ICU
•
•
•
•
•
•
•
•
•
•
•
•
•
Need for intubation
Seizures
Unresponsiveness to verbal stimuli
Arterial carbon dioxide pressure greater than 45 mm Hg
Cardiac conduction or rhythm disturbances (any rhythm except sinus arrhythmia)
Close monitoring of vital signs during antidotal therapy or elimination procedures
The need for continuous monitoring
QRS interval greater than 0.10 second, in cases of tricyclic antidepressant
poisoning
Systolic blood pressure less than 80 mm Hg
Hypoxia, hypercarbia, acid-base imbalance, or metabolic abnormalities
Extremes of temperature
Progressive deterioration or significant underlying medical disorders
Suicidality
Mofenson HC et al, Medical Toxicology, Physical and Chemical Injuries, Bope & Kellerman: Conn's
Current Therapy 2013
Diagnostic algorithm using
the size of the pupils
Ford MD, Acute Poisoning, Goldman's Cecil Medicine, 24th ed., 2011.
Apply DSM-IV Diagnostic Criteria
for Alcohol Withdrawal
Highlights of Changes from
DSM-IV-TR to DSM-5
•
•
DSM-5 does not separate the diagnoses of substance abuse and dependence as
in DSM-IV. Rather, criteria are provided for substance use disorder, accompanied
by criteria for intoxication, withdrawal, substance/medication-induced disorders,
and unspecified substance-induced disorders, where relevant.
The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV
substance abuse and dependence criteria combined into a single list, with two
exceptions.
– The DSM-IV recurrent legal problems criterion for substance abuse has been deleted
from DSM-5, and a new criterion, craving or a strong desire or urge to use a substance,
has been added.
– In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two
or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of
DSM-IV substance abuse and three or more for DSM-IV substance dependence.
•
Cannabis withdrawal is new for DSM-5, as is caffeine withdrawal (which was in
DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”).
American Psychiatric Association. Highlight of Changes from DSM-IV-TR to DSM-5.
http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
Highlight of Changes from
DSM-IV-TR to DSM-5
•
Of note, the criteria for DSM-5 tobacco use disorder are the same as those for
other substance use disorders. By contrast, DSM-IV did not have a category for
tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for
tobacco in DSM-5.
•
Severity of the DSM-5 substance use disorders is based on the number of criteria
endorsed: 2–3 criteria indicate a mild disorder; 4–5 criteria, a moderate disorder;
and 6 or more, a severe disorder.
•
The DSM-IV specifier for a physiological subtype has been eliminated in DSM-5, as
has the DSM-IV diagnosis of polysubstance dependence.
•
Early remission from a DSM-5 substance use disorder is defined as at least 3 but
less than 12 months without substance use disorder criteria (except craving), and
sustained remission is defined as at least 12 months without criteria (except
craving).
•
Additional new DSM-5 specifiers include “in a controlled environment” and “on
maintenance therapy” as the situation warrants.
American Psychiatric Association. Highlight of Changes from DSM-IV-TR to DSM-5.
http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
Substance-related disorders
DSM-5 classification
• Substance use disorders
• Substance-induced disorders
– Substance intoxication
– Substance withdrawal
• Substance/medication-induced mental
disorders
• Other substance-induced disorders
• Unspecified substance-related disorder
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance-related disorders
10 classes of drugs
•
•
•
•
alcohol
caffeine
cannabis
hallucinogens
– PCP
– other hallucinogens
• Inhalants
• opioids
• sedatives, hypnotics,
and anxiolytics
• stimulants
(amphetamine-type
substances, cocaine,
and other stimulants)
• tobacco
• other (or unknown)
substances
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Abuse versus dependence
DSM IV-TR
Alcohol abuse
Alcohol dependence
A. A maladaptive pattern of drinking, leading
to clinically significant impairment or distress,
as manifested by at least one of the following
occurring within a 12-month period:
A. A maladaptive pattern of drinking, leading to clinically
significant impairment or distress, as manifested by three
or more of the following occurring at any time in the
same 12-month period:
•Need for markedly increased amounts of alcohol to achieve
intoxication or desired effect; or markedly diminished effect with
continued use of the same amount of alcohol
•Recurrent use of alcohol resulting in a failure to fulfill
major role obligations at work, school, or home (e.g.,
repeated absences or poor work performance related to
alcohol use; alcohol-related absences, suspensions, or
expulsions from school; neglect of children or household)
•Recurrent alcohol use in situations in which it is physically
hazardous (e.g., driving an automobile or operating a
machine when impaired by alcohol use)
•Recurrent alcohol-related legal problems (e.g., arrests for
alcohol-related disorderly conduct)
•Continued alcohol use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol (e.g., arguments with
spouse about consequences of intoxication).
B. Never met criteria for alcohol dependence.
•The characteristic withdrawal syndrome for alcohol; or drinking (or
using a closely related substance) to relieve or avoid withdrawal
symptoms
•Drinking in larger amounts or over a longer period than intended.
•Persistent desire or one or more unsuccessful efforts to cut down or
control drinking
•Important social, occupational, or recreational activities given up or
reduced because of drinking
•A great deal of time spent in activities necessary to obtain, to use, or
to recover from the effects of drinking
•Continued drinking despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to be caused
or exacerbated by drinking.
B. No duration criterion separately specified, but several
dependence criteria must occur repeatedly as specified
by duration qualifiers associated with criteria (e.g.,
“persistent,” “continued”).
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.).
Substance-use disorders
Diagnostic criteria
• Criteria A
– Impaired control (Criteria 1-4)
– Social impairment (Criteria 5-7)
– Risky use (Criteria 8-9)
– Pharmacological criteria (Criteria 10-11)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria
A. A problematic pattern of __ use leading to
clinically significant impairment or distress, as
manifested by at least two or the following,
occuring within a 12-month period:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria
1. __ is often taken in larger amounts or over a
longer period than was intended.
2. There is a persistent desire or unsuccessful
efforts to cut down or control __ use.
3. A great deal of time in spent in activities
necessary to obtain __, use __, or recover from
its effects.
4. Craving, or a strong desire or urge to use __.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria
5. Recurrent __ use resulting in a failure to fulfill
major role obligations at work, school, or home
6. Continued __ use despite having persistent or
recurrent social or interpersonal problems
caused or exacerbated by the effects of __.
7. Important social, occupational, or recreational
activities are given up or reduced because of __
use.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria
8. Recurrent __ use in situations in which it is
physically hazardous.
9. Alcohol use is continued despite knowledge
of having a persistent or recurrent physical or
psychological problem that is likely to have
been caused or exacerbated by __.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria
10. Tolerance, as defined by either of the following:
– a. A need for markedly increased amounts of __ to achieve
intoxication or desired effect.
– b. A markedly diminished effect with continued use of the
same amount of __.
11. Withdrawal, as manifested by either of the
following:
– a. The characteristic withdrawal syndrome for __
– b. __ (or a closely related substance) is taken to relieve or
avoid withdrawal symptoms.
Substance use disorders
Diagnostic criteria
• Specifiers
– In early remission: no criteria met at least 3 months but
less than 12 months
– In sustained remission: no criteria met for 12 months or
longer
– In a controlled environment
– Severity
• Mild: presence of 2-3 symptoms
• Moderate: presence of 4-5 symptoms
• Severe: presence of 6 or more symptoms
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance Intoxication
Diagnostic Criteria
A. Recent ingestion of __.
B. Clinically significant problematic behavioral or
psychological changes (e.g., __) that developed
during, or shortly after, __ use.
C. # (or more) of the following signs of symptoms
developing during, or shortly after, __ use:
D. The signs or symptoms are not attributable to
another medical condition and are not better
explained by another mental disorder, including
intoxication with another substance.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance withdrawal
Diagnostic Criteria
A. Cessation of (or reduction in) __ use that has been heavy and
prolonged.
B. # (or more) of the following signs and symptoms developing within
__ after Criteria A.
C. The signs or symptoms in Criteria B cause clinically significant
distress or impairment in social, occupational, or other important
areas of functioning.
D. The signs or symptoms are not attributable to another medical
condition, and are not better explained by another mental disorder,
including intoxication or withdrawal from another substance.
Specifier: with perceptual disturbance.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Permutations
•
•
•
•
10 substances x 5 conditions = 50
Exceptions:
No caffeine intoxication disorder
No hallucinogen or inhalant withdrawal
disorders
• Hallucinogen persisting perception disorder
• No tobacco intoxication disorder
• Gambling disorder
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Alcohol
Intoxication
Withdrawal (2+ within hrs-days)
B. Inappropriate sexual or aggressive
behavior, mood lability, impaired
judgment
•Autonomic hyperactivity
C. 1 or more of:
•Insomnia
•Slurred speech
•Incoordination
•E.g., sweating or pulse rate >100 bpm
•Increased hand tremor
•Nausea or vomiting
•Unsteady gait
•Transient visual, tactile, or auditory
hallucinations or illusions
•Nystagmus
•Psychomotor agitation
•Impairment in attention or memory
•Anxiety
•Stupor or coma
•Generalized tonic-clonic seizures
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Alcohol BAC and effects
Kelly JF, Renner JA, Alcohol-Related Disorders, Massachusetts General Hospital Comprehensive
Clinical Psychiatry
Alcohol withdrawal time course
4 classic categories: withdrawal tremulousness,
hallucinations, seizures, and DT
ALCOHOL ABUSE AND DEPENDENCE
PATRICK G. O’CONNOR
O’Connor PG, Alcohol Abuse And
Dependence, Goldman L, Ausiello D, eds.
Cecil Medicine. 23rd ed. Philadelphia, Pa:
Saunders Elsevier; 2007:chap 31.
CAGE questionnaire
1.Have you ever felt you needed to Cut down on your drinking?
2.Have people Annoyed you by criticizing your drinking?
3.Have you ever felt Guilty about drinking?
4.Have you ever felt you needed a drink first thing in the
morning (Eye-opener) to steady your nerves or to get rid of a
hangover?
CAGE test scores >=2 is positive
Excessive drinking: specificity 76%, sensitivity of 93%
alcoholism: specificity of 77%, sensitivity of 91%
Kitchens JM (1994). "Does this patient have an alcohol problem?". JAMA 272 (22):1782–7.
Alcohol withdrawal syndrome
admission management goals
1. Monitor course of syndrome, ensuring patient safety
2. Use methods to abort progression and treat
symptoms
3. Manage comorbid medical, surgical, toxicologic, and
psychiatric problems
4. Anticipate need for intensive care monitoring and
therapy
5. Ensure multidisciplinary approach to management,
including preparation for rehabilitation
Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585
Objectives for alcohol withdrawal
services
1. To interrupt a pattern of heavy and regular alcohol use
2. To alleviate withdrawal symptoms
3. To prevent severe withdrawal complications
4. Facilitate linkages to ongoing treatment for alcohol
dependence.
5. To get help with any other problems
N.B. Successful completion of alcohol withdrawal does not
prevent recurrent alcohol consumption and additional
interventions are needed to achieve long-term
Australian Alcohol Guidelines.
Admission studies for patients with moderate to
severe alcohol withdrawal syndrome
1. Complete blood cell count
2. Baseline metabolic panel with serum electrolytes (including magnesium), glucose, renal
function tests
3. Blood alcohol, and urine and blood toxicology studies
4. Serum calcium, phosphate, lipase, CPK activity
5. Liver function tests, including INR and serum AST, ALT, bilirubin, ammonia
6. Chest radiograph
7. Electrocardiogram, cardiac biomarkers, echocardiogram
8. Urinalysis
9. Arterial blood gas analysis
10. Blood, urine, and sputum cultures
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CPK, creatine
phosphokinase; INR, international normalized ratio.
a Laboratory, imaging, and clinical evaluations must be individualized.
Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585
Alcohol labs
Blood alcohol level
Alcohol-use disorders
Marc A Schuckit, Lancet 2009; 373: 492–501
Alcohol treatment medications
O’Connor PG, Alcohol Abuse And Dependence, Goldman L, Ausiello D, eds. Cecil Medicine. 23rd
ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 31.
UNM CIWA protocol
Risk factors for severe course of AWS,
including seizures and delirium
1. Prior episodes of AWS requiring detoxification, including seizures or delirium (kindling)
2. Grade 2 severity or higher on presentation (CIWA-Ar Score >10)
3. Advanced age
4. Acute or chronic comorbid conditions, including alcoholic liver disease, co-intoxications,
trauma, infections, sepsis
5. Detectable blood alcohol level on admission
6. Use of “eye opener,” high daily intake of alcohol, or number of drinking days/month
7. Abnormal liver function (serum aspartate aminotransferase activity >80 U/L)
8. Prior benzodiazepine use
9. Male sex
Abbreviation: CIWA-Ar, Clinical Institute of Withdrawal Assessment for Alcohol, revised.
Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585
Potential indications for ICU
management
1. Advanced Stage 2 or greater alcohol withdrawal syndrome
2. Critical comorbid conditions including: trauma; severe sepsis; respiratory
failure; acute respiratory distress syndrome; hemodynamic instability;
gastrointestinal bleeding; hepatic failure; pancreatitis; rhabdomyolysis;
co-intoxication; coagulopathies; acute CNS process; cardiac arrhythmias,
ischemia, or congestive failure; severe fluid or electrolyte defects; renal
failure; persistent fever; or complex acid-base defects
3. Escalating intravenous bolus or continuous-infusion sedation therapy
4. Persistent fever >39 C
Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585
Delirium
Diagnostic Criteria
A.
A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift
attention) and awareness (reduced orientation to the environment).
B.
The disturbance develops over a short period of time (usually hours to a few
days), represents a change from baseline attention and awareness, and tends to
fluctuate in severity during the course of a day.
C.
An additional disturbance in cognition (e.g., memory deficit, disorientation,
language, visuospatial ability, or perception).
D.
The disturbances in Criteria A or C are not better explained by another
preexisting, established, or evolving neurocognitive disorder and do not occur
in the context of a severely reduced level of arousal, such as coma.
E.
There is evidence from the history, physical examination, or laboratory findings
that the disturbance is a direct physiological consequence of another medical
condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or
to a medication), or exposure to a toxin, or is due to multiple etiologies.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Delirium
Diagnostic criteria
Specifiers:
Substance intoxication delirium
Substance withdrawal delirium
Medication-induced delirium
Delirium due to multiple etiologies
Delirium due to another medical condition
Acute: lasting a few hours or days
Persistent: lasting weeks or months
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Differentiate delirium tremens from
other alcohol withdrawal syndromes
• 5% of patients with alcohol withdrawal
• Constellation of symptoms: confusion, hallucinations, fever
(with or without evidence of infection), and autonomic
hyperresponsiveness with hypertension and profound
tachycardia
• Suspect in any agitated patient withdrawing from alcohol
with BP >140/90 mm Hg, HR > 100/min, T > 101 Fahrenheit
• Mortality 5-15%
Erwin WE et al, Delirium tremens, Southern Medical Journal (May 1998, 91:5), 425-432.
Acetaminophen metabolism
Salhanick SD, Shannon MW,
Acetaminophen, Haddad and
Winchester's Clinical
Management of Poisoning
and Drug Overdose, 4th ed.,
2007.
Algorithm showing
current
recommendations
for N-acetylcysteine
(NAC) treatment of
acetaminophen
overdose.
Chun LJ et al,
Acetaminophen
Hepatotoxicity and
Acute Liver Failure,
J Clin
Gastroenterol
2009;43:342–349.
Caffeine
Intoxication (5 or more of):
Withdrawal (3 or more within 24 hr of:)
•Restlessness
•Headache
•Nervousness
•Marked fatigue or drowsiness
•Excitement
•Insomnia
•Dysphoric mood, depressed mood, or
irritability
•Flushed face
•Difficulty concentrating
•Diuresis
•Flu-like symptoms (nausea, vomiting, or
muscle pain/stiffness)
•Gastrointestinal disturbance
•Muscle twitching
•Rambling flow of thought and speech
•Tachycardia or cardiac arrhythmia
•Periods of inexhaustibility
•Psychomotor agitation
American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
Cannabis
Intoxication
Withdrawal (3 or more within 1 wk:)
B. Impaired motor coordination,
euphoria, anxiety, sensation of
slowed time, impaired judgment,
social withdrawal
•Irritability, anger, or aggression
C. 2 or more within 2 hrs of:
•Conjunctival injection
•Increased appetite
•Dry mouth
•tachycardia
•Nervousness or anxiety
•Sleep difficulty (e.g., insomnia,
disturbing dreams)
•Decreased appetite or weight loss
•Restlessness
•Depressed mood
•At least one of the following
physical symptoms causing
significant discomfort: abdominal
pain, shakiness/tremors, sweating,
fever, chills, or headache
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Synthetic marijuana
Spice and K2
• Synthetic marijuana (often known as “K2” or “Spice”)consists of plant
material that has been laced with substances (synthetic cannabinoids)
that users claim mimics Δ9-tetrahydrocannabinol(THC), the primary
psychoactive active ingredient in marijuana, and are marketed toward
young people as a “legal” high.
• According to data from the 2011 Monitoring the Future survey of
youth drug-use trends, 11.4 percent of 12th graders used Spice or K2
in the past year, making it the second most commonly used illicit drug
among seniors.
• The effects of synthetic marijuana include agitation, extreme
nervousness, nausea, vomiting, tachycardia (fast, racing heartbeat),
elevated blood pressure, tremors and seizures, hallucinations, and
dilated pupils.
White House, Office of National Drug Control Policy, Synthetic Drugs (a.k.a. K2, Spice, Bath Salts,
etc.), http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice-bath-salts
Proposed Clinical Criteria for
Cannabinoid Hyperemesis
Essential for diagnosis
•
Long-term cannabis use
Major features
•
•
•
•
•
Severe cyclic nausea and vomiting
Resolution with cannabis cessation
Relief of symptoms with hot showers or baths
Abdominal pain, epigastric or periumbilical
Weekly use of marijuana
Supportive features
•
•
•
•
•
Age less than 50 y
Weight loss of >5 kg
Morning predominance of symptoms
Normal bowel habits
Negative laboratory, radiographic, and endoscopic test results
Simonetto DA et al, Cannabinoid Hyperemesis: A Case Series of 98 Patients,
Mayo Clin Proc. 2012;87(2):114-119
Hallucinogens
PCP Intoxication
Other hallucinogen intoxication
B. belligerence, assaultiveness, impulsiveness,
unpredictability, psychomotor agitation,
impaired judgment
B. Marked anxiety or depression, ideas of
reference, fear of “losing one’s mind,”
paranoid ideation, impaired judgment
C. 2 or more within 1 hr:
C. 2 or more of:
•Vertical or horizontal nystagmus
•Pupillary dilation
•Hypertension or tachycardia
•Tachycardia
•Numbness or diminished responsiveness to
pain
•Sweating
•Ataxia
•Dysarthria
•Palpitations
•Blurring of vision
•Muscle rigidity
•Tremors
•Seizures or coma
•incoordination
•hyperacusis
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Jimson weed
Datura stramonium
•
Contains anticholinergics atropine and scopolamine and is
hallucinogenic
•
Symptoms of toxicity usually occur within 30-60 minutes after
ingestion and may continue for 24-48 hours because the alkaloids
delay gastrointestinal motility.
•
Ingestion of Jimson weed manifests as classic atropine poisoning.
Initial manifestations include dry mucous membranes, thirst, difficulty
swallowing and speaking, blurred vision, and photophobia, and may
be followed by hyperthermia, confusion, agitation, combative
behavior, hallucinations typically involving insects, urinary retention,
seizures, and coma.
•
Treatment consists of supportive care, gastrointestinal
decontamination (i.e., emesis and/or activated charcoal), and
physostigmine in severe cases.
Epidemiologic Notes and Reports Jimson Weed Poisoning -- Texas, New York, and
California, 1994. MMWR (1995) 44(03);41-44.
https://en.wikipedia.org/wiki/Datura_stramonium
Inhalant Intoxication
B. belligerence, assaultiveness,
apathy, impaired judgment
•Depressed reflexes
C. 2 or more of:
•Tremor
•Dizziness
•Generalized muscle weakness
•Nystagmus
•Blurred vision or diplopia
•Incoordination
•Stupor or coma
•Slurred speech
•Euphoria
•Psychomotor retardation
•Unsteady gait
•Lethargy
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Opioids
Intoxication
Withdrawal (3+ within min-days:)
B. Initial euphoria followed by
apathy, dysphoria, psychomotor
agitation or retardation, impaired
judgment
•Dysphoric mood
C. Pupillary constriction (or pupillary
dilation due to anoxia from severe
overdose) + 1 or more of:
•Nausea or vomiting
•Muscle aches
•Lacrimation or rhinorrhea
•Pupillary dilation, piloerection, or
sweating
•Drowsiness or coma
•Diarrhea
•Slurred speech
•Yawning
•Impairment in attention or memory
•Fever
•insomnia
Management of injecting drug users
admitted to hospital
Paul S Haber, Abdullah Demirkol,
Kezia Lange, Bridin Murnion, Lancet
2009; 374: 1284–93
Sedative-, Hypnotic-, or Anxiolyticrelated disorders
Intoxication
Withdrawal (2+ within hrs-few days)
B. Inappropriate sexual or aggressive
behavior, mood lability, impaired
judgment
•Autonomic hyperactivity (e.g.,
sweating or pulse greater than 100
bpm)
C. 1 or more of:
•Hand tremor
•Slurred speech
•Insomnia
•Incoordination
•Nausea or vomiting
•Unsteady gait
•Transient visual, tactile, or auditory
hallucinations or illusions
•Nystagmus
•Impairment in cognition (e.g.,
attention, memory)
•Psychomotor agitation
•Stupor or coma
•Grand mal seizures
•Anxiety
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Stimulants
Intoxication
Withdrawal
B. Euphoria or affective blunting; changes in
sociability; hyperviligance; interpersonal
sensitivity; anxiety, tension, or anger;
stereotyped behaviors; impaired judgment
Dysphoric mood + 2+ within few hours-days:
C. 2 or more of:
•Tachycardia or bradycardia
•Pupillary dilation
•Elevated or lowered blood pressure
•Perspiration or chills
•Nausea or vomiting
•Evidence of weight loss
•Psychomotor agitation or retardation
•Muscular weakness, respiratory depression,
chest pain, or cardiac arrhythmias
•Confusion, seizures, dyskinesias, dystonias, or
coma
•Insomnia or hypersomnia
•Fatigue
•Vivid, unpleasant dreams
•Increased appetite
•Psychomotor retardation or agitation
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Bath salts
• •Bath salts contain manmade chemicals related to
amphetamines that often consist of
methylenedioxypyrovalerone (MDPV), mephedrone,
and methylone, also known as substituted
cathinones.
• Similar to the adverse effects of cocaine, LSD and
methamphetamine, bath salt use is associated with
increased heart rate and blood pressure, extreme
paranoia, hallucinations, and violent behavior, which
causes users to harm themselves or others.
White House, Office of National Drug Control Policy, Synthetic Drugs (a.k.a. K2, Spice, Bath Salts,
etc.), http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice-bath-salts
Amphetamine effects
Albertson TE et al, Amphetamines and derivatives, Haddad and Winchester's Clinical
Management of Poisoning and Drug Overdose, 4th ed.200
“Faces of Meth”
Faces of Meth, Multnomah County Sheriff’s Office,
http://www.facesofmeth.us/
Albertson TE et al,
Amphetamines and
derivatives, Haddad
and Winchester's
Clinical
Management of
Poisoning and Drug
Overdose, 4th
ed.200
Amphetamine treatment algorithm
Albertson TE et al, Amphetamines and derivatives, Haddad and Winchester's Clinical
Management of Poisoning and Drug Overdose, 4th ed.200
Tobacco Withdrawal
Cessation followed within 24 hours by four (or
more) of the following signs or symptoms:
• Irritability, frustration, or anger
• Anxiety
• Difficulty concentrating
• Increased appetite
• Depressed mood
• insomnia
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Other (or Unknown) Substances
•
•
•
•
•
•
•
•
•
•
Anabolic steroids
Nonsteroidal anti-inflammatory drugs
Cortisol
Antiparkinsonian medications
Antihistamines
Nitrous oxide
Amyl-, butyl-, or isobutyl-nitrites
Betel nut
Kava
Cathinones (e.g., khât)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance/medication-induced
mental disorders
A.
The disorder represents a clinically significant presentation of a relevant mental disorder.
B.
There is evidence from the history, physical examination, or laboratory findings of both of
the following:
C.
1.
The disorder developed during or within 1 month of a substance intoxication or withdrawal or
taking a medication; and
2.
The involved substance/medication is capable of producing the mental disorder.
The disorder is not better explained by an independent mental disorder (i.e., one that is
not substance- or medication-induced). Such evidence of an independent mental disorder
could include the following:
1.
The disorder preceded the onset of severe intoxication or withdrawal or exposure to the
medication; or
2.
The full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the
cessation of acute withdrawal or severe intoxication or taking the medication. This criterion does
not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception
disorder, which persist beyond the cessation of acute intoxication or withdrawal.
D.
The disorder does not occur exclusively during the course of a delirium.
E.
The disorder causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Substance/medication-induced
mental disorders
•
•
•
•
•
•
•
Psychotic disorders
Bipolar disorders
Depressive disorders
Anxiety disorders
Obsessive-compulsive and related disorders
Sleep disorders
Sexual dysfunctions
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Discussion &
Action Items
• Which labs are needed for patients with
overdose? Do all such patients need to be
admitted? If not, when is it safe to discharge
them?
• Do all alcohol withdrawal patients need to be
admitted? If not, when, to where, and with
what medications (if any)?